Menstrual Disorders

Question 1

Types of menstrual Disorders (7)

Answer 1

Amenorrhoea –> lack of periods
Dysmenorrhoea –> painful periods
Menorrhagia –> heavy or long periods (HMB)
Metrorrhagia –> irregular or spotting
Dysfunctional uterine bleeding (DUB) & premenstrual syndrome (PMS)

Question 2

Definition of Heavy menstrual bleeding (HMB)

Answer 2

Excessive blood loss which interferes with a woman’s physical, emotional, social or material quality of life (NICE 2007)

Question 3

Incidence of HMB

Answer 3

1/20 women between 30-49 see their GP each year for HMB –>accounts for 12% of gynae OP referrals
Medical Tx costs –£7million
Surgical Tx costs– £98.4million

Question 4

Treatment of HMB

Answer 4

Used to treat with hysterectomy (60%)

Pharmacotherapy if no adnormality or fibroids USS then treat surgically

Question 5

Causes of HMB

Answer 5

Fibroids
Endometriosis or adenomyosis 
Endometrial or cervical polyps
Infection or Cancer
Pregnancy
Thromopathies or thyroid disease

Question 6

Fibroids

Answer 6

Can be Submucosal (growing into the inside of the uterus)

Can be subserosal (growing out of the surface of the uterus)

Question 7

Assessment of HMB – History

Answer 7

Duration of symptoms
Cycle length and bleed duration
Associated symptoms (pain/dyspareunia) or intermenstrual or postcoital bleeding
Smear history
PMH and POH

Question 8

Assessment of HMB – Examiation

Answer 8

General –> then abdominal –> then speculum –> then bimanual

Question 9

Assessment of HMB – Investigations

Answer 9

FBC and thyroid test if indicated
USS (transvaginal)
Hysteroscopy or Laparoscopy
If persistent, in women >45rs or unresponsive to treatment –> endometrial biopsy may be indicated

Question 10

Assessment of HMB – Investigations which are not needed

Answer 10

Measurements of blood loss
Serum ferritin test
Female hormone tests
Saline infusion sonography or MRI as a first line investgation 
Dilatation and Curettage

Question 11

Surgical treatments of HMB

Answer 11

If want to retain fertility–> Uterine artery embolisation or myomectomy
If no desire to retain fertility–> Endometrial ablation or hysterectomy

Question 12

Pharmacotherapy for HMB

Answer 12

Coagulants (tranexamic or mefenamic acid)
IUS (mirena)
Combined or progestagen only pills
Other–> NSAIDs or GnRH analogues

Question 13

Mirena coil

Answer 13

Prevents endomentrial proliferation by progestagen release
A contraceptive with no impact on future fertility
Can cause irregular bleeding and hormone related side effects and, rarely, uterine perforation

Question 14

Tranexamic acid

Answer 14

Oral antifibrinolytic (Non-hormonal) and can be used along side investigation for up to 3 cycles–> continue if improvement
Not a contraceptive with no effect on fertility
SEs–> indigestion, diarrhoea, headaches

Question 15

NSAIDs

Answer 15

Reduce production of prostaglandins,often used for dysmenorrhoea
No contraceptive effect/on fertility
SEs–>indigestions, diarrhoea, asthma and GI bleeding

Question 16

COC

Answer 16

acts by preventing endometrial proliferation, so contraceptive without long term impact on fertility
SEs–> mood changes, headache, nasea, fluid retention, breast tenderness, increased risk of DVT/stroke/MI

Question 17

Progestagen only pill (Norethisterone)

Answer 17

Taken day 5-26 of cycle
Contraceptive which prevents endometrial proliferation
SEs–> weight gain, bloating, breast tenderness, headaches, acne, depression

Question 18

Progestagen Injection (Depo-provera)

Answer 18

Contraceptive which prevents endometrial proliferation

SEs–> weight gain, bloating, breast tenderness, headaches,amenorrhoea, less commonly bone density loss

Question 19

GnRH analogues

Answer 19

An injection which stops estrogen and progesterone production–> not a contraceptive, if used for more than 6 months HRT is indicated
SEs–> menopausal symptoms and low risk of osteoporosis

Question 20

Hysteroscopic Endometrial Ablation

Answer 20

First used Rollerball, now balloon and microwave
Destroys the endometrium so impacts fertility
Still should consider contraception
Can cause discharge, perforation or require further surgery

Question 21

Medical treatment protocols of HMB

Answer 21

Pharmacological–> Mirena IUS (must be used for 12 months or more)–> Tranexamic acid OR NSAIDs OR COC –> Progestagen only method

Question 22

Myomectomy

Answer 22

Can be abdominal or hysteroscopic
Aims to retain fertility but small risk of hysterectomy during abdominal myomectomy
Can cause haemorrhage, infection, adhesions and need for more surgery

Question 23

Hysterectomy

Answer 23

Can also take ovaries, can be subtotal or total
1st line vaginal, 2nd line abdominal
Can lead to infection, haemorrhage, DVT or urinary dysfunction

Question 24

Uterine artery embolisation (UAE)

Answer 24

Used to treat large fibroids avoiding surgery and sparing the uterus–> particles are injected to the uterine artery to block the blood supply to the fibroid
Aim to preserve fertility but can lead to premature menopause (also discharge, post-UAE syndrome, infection or haemorrhage)

Question 25

Subtotal hysterectomy

Answer 25

Just the body of the uterus is removed, so the cervix is still in place

Question 26

Total hysterectomy

Answer 26

Uterus and cervix removed

Preferred because there is no risk of cervical cancer

Question 27

Norethisterone in menorrhagia

Answer 27

5mg can be used as short term option to rapidly stop heavy menstrual bleeding